BV Travel Clinic for All Patients Registered At

BV Travel Clinic for all patients registered at:

Acorn Practice - Cam & Uley Family Practice - The Chipping Surgery- The Culverhay Surgery - Marybrook Medical Centre - Walnut Practice

TRAVELRISKASSESSMENT FORM–ideallytobecompleted bytravelerpriortoappointment.

Name:
GP Practice: / Dateof birth:
Male □ Female□
Email: / Telephone number:
Mobilenumber:
PLEASESUPPLY INFORMATIONABOUTYOURTRIP INTHESECTIONS BELOW
Dateof departure: / Total lengthof trip:
COUNTRYTO BEVISITED / EXACTLOCATIONORREGION / CITYORRURAL / LENGTHOF STAY
1.
2.
3.
Haveyoutaken outtravelinsurancefor thistrip? Doyouplan totravelabroadagaininthe future?
TYPE OFTRAVELANDPURPOSE OF TRIP-PLEASE TICKALLTHAT APPLY
□Holiday □Stayinginhotel □Backpacking Additionalinformation
□Businesstrip □Cruiseshiptrip □Camping/hostels
□Expatriate □Safari □Adventure
□Volunteerwork □Pilgrimage □ Diving
□Healthcare worker □ Medicaltourism □Visitingfriends/family
PLEASESUPPLYDETAILSOFYOURPERSONAL MEDICAL HISTORY
YES / NO / DETAILS
Areyoufitand welltoday
Any allergiesincludingfood,latex,medication
Severereactiontoavaccinebefore
Tendency tofaintwithinjections
Any surgicaloperations inthepast,includinge.g.your
spleenorthymus glandremoved
Recentchemotherapy/radiotherapy/organtransplant
Anemia
Bleeding/clottingdisorders(includinghistory ofDVT)
Heart disease(e.g. angina, highbloodpressure)
Diabetes
Disability
Epilepsy/seizures
Gastrointestinal(stomach) complaints
Liverandor kidneyproblems
HIV/AIDS
Immunesystemcondition

FormdevisedandcreatedbyJaneChiodini©updated 2017

YES / NO / DETAILS
Mentalhealthissues(includinganxiety, depression)
Neurological(nervous system) illness
Respiratory(lung)disease
Rheumatology(joint) conditions
Spleenproblems
Any other conditions?
Womenonly
Areyoupregnant?
Areyoubreastfeeding?
Areyou planningpregnancy whileaway?
Have you undergone FGM / been cut / circumcised

Are you currently takingany medication(including prescribed,purchasedoracontraceptivepill)?

PLEASESUPPLY INFORMATIONONANYVACCINES OR MALARIATABLETSTAKEN INTHEPAST
Tetanus/polio/diphtheria / MMR / Influenza
Typhoid / HepatitisA / Pneumococcal
Cholera / HepatitisB / Meningitis
Rabies / Japanese
Encephalitis / Tick Borne
Encephalitis
Yellow fever / BCG / Other
MalariaTablets

Any additionalinformation

Please send your completed form to:

The BV Travel clinic nurse will contact you between the following times: Monday 1.30pm – 7pm Thursday 1.30pm – 6.00pm

1. Chiodini J,BoyneL, GrieveS, Jordan A.(2007)Competencies: AnIntegratedCareerandCompetency Framework forNurses in Travel

HealthMedicine. RCN, London.

2.FieldVK, FordL, Hill DR,eds. (2010)HealthInformationforOverseas Travel.National Travel Health NetworkandCentre, London, UK.